HOW NURSE PRACTITIONERS WORKING IN RURAL COMMUNITIES CAN
REDUCE THE BARRIERS TO ACCESS PRIMARY HEALTH CARE SERVICES FOR
OLDER ADULTS

by

Elizabeth Helen Enes
B.Sc.N., University of Northern British Columbia, 2013

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
THE DEGREE OF MASTERS OF SCIENCE IN NURSING: FAMILY NURSE
PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
June 2021

© Elizabeth H. Enes, 2021

ii
Abstract
Due to the aging population worldwide, need to access primary health care (PHC)
services is increasing. Older adults are at a heightened risk of developing chronic diseases, poor
health outcomes, and increased emergency department visits. Living in rural communities also
increases the risk of chronicity for older adults due to a lack of PHC resources. However, there is
limited information available to provide insight into how healthcare providers can reduce barriers
to access to PHC for older adults. As PHC providers, nurse practitioners are in a position to
implement strategies to reduce barriers older adults in rural communities face with accessing
PHC services. An integrative literature review was conducted to identify barriers nurse
practitioners within rural communities can reduce to improve older adults’ access to PHC
services. An analysis of the literature revealed the complexity of barriers that prevent older
adults from accessing PHC services in rural communities. Environmental, systemic, and
individual barriers were reviewed alongside programs and interventions relevant to reducing
barriers in the findings. Findings from the literature review suggested strategies to reduce these
barriers, which nurse practitioners can promote in the PHC setting. These strategies include
virtual care, home visits, nurse practitioner-models of care, interdisciplinary teamwork, and role
clarification. In addition to these strategies, implications for practice, limitations of the study and
suggestions for future research are discussed.

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Table of Contents
Abstract ........................................................................................................................................... ii
List of Tables and Figures............................................................................................................... v
Acknowledgements ........................................................................................................................ vi
Chapter I: Introduction .................................................................................................................... 1
Chapter II: Background and Context .............................................................................................. 3
Concepts ...................................................................................................................................... 4
Nurse Practitioners .................................................................................................................. 4
Older Adults ............................................................................................................................ 5
Primary Health Care ................................................................................................................ 6
Rural Communities .................................................................................................................. 6
Access to Primary Health Care ................................................................................................... 7
Barriers to Accessing Primary Health Care ................................................................................ 9
Environmental Barriers.......................................................................................................... 10
Systemic Barriers ................................................................................................................... 11
Individual Barriers ................................................................................................................. 11
Nurse Practitioners as Primary Health Care Providers ............................................................. 13
Chapter III: Methods ..................................................................................................................... 15
Search Strategies ....................................................................................................................... 15
Inclusion and Exclusion Criteria ............................................................................................... 15
Search Results ........................................................................................................................... 17
Chapter IV: Findings..................................................................................................................... 18
Virtual Care ............................................................................................................................... 19
Telemedicine and Telehealth ..................................................................................................... 19
Integrating Nurse Practitioner-Models of Care ......................................................................... 23
Home Visits ............................................................................................................................... 27
Interdisciplinary Teams ............................................................................................................. 28
Role Clarification ...................................................................................................................... 32
Chapter V: Discussion .................................................................................................................. 36
Older Adults’ Perspective ......................................................................................................... 40
Limitations ................................................................................................................................ 41
Implications for Practice ............................................................................................................... 42

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Future Research ............................................................................................................................ 44
Conclusion .................................................................................................................................... 44
References ..................................................................................................................................... 46
Table 1 .......................................................................................................................................... 54
Table 2 .......................................................................................................................................... 55
Table 3 .......................................................................................................................................... 57
Table 4 .......................................................................................................................................... 58
Figure 1. Literature Search Flow Diagram for Search Conducted September, 2020 ................... 59
Appendix A ................................................................................................................................... 60

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List of Tables and Figures
Table 1: Concept Table for Search Strategy
Table 2: Comprehensive Search Strategy (September 25, 2020)
Table 3: Brainstorming Concepts
Table 4: PubMed Search and Results
Table 5: Inclusion and Exclusion Criteria of Literature Search
Figure 1: Literature Search Flow Diagram for Search Conducted September, 2020

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Acknowledgements
I would like to express my deepest gratitude to my advisory committee members Dr.
Shannon Freeman and Linda Van Pelt, for their expertise, guidance and continued support
throughout this process which helped me complete this project.
I would also like to thank my husband, Luis, for his love and encouragement. My
daughter, Isabelle, for inspiring me. My parents, Wayne and Janet, for believing in me. My
friends, those I made in the program, and those who have always been there, thank you for being
my cheerleaders. I could not have done this without all of your motivation, compassion, and
love.

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Chapter I: Introduction
With the increase in the aging population throughout the world, there is a heightened
need for access to adequate healthcare services within this population (Ford et al., 2018). Access
to healthcare services, such as PHC, has been widely linked to reduced hospital admissions for
older adults with chronic conditions, decreased emergency department visits, and better overall
health outcomes (Kurpas et al., 2018; Weaver et al., 2014). Older adults who reside in rural
communities have higher healthcare needs due to their increasing comorbidities and limited
access to PHC (Ford et al., 2015). Nurse practitioners are often involved in delivering PHC to
this population. Additionally, with the projected increase in the population over the age of 65,
older adults will become a significant portion of nurse practitioner caseloads (Auerhahn et al.,
2012).
Nurse practitioners play an important role in the provision of PHC services (Auerhahn et
al., 2012). Throughout Canada and many parts of the world, nurse practitioners are being utilized
to provide PHC to patients in rural communities. Several of these rural communities have
experienced shortages of PHC providers and nurse practitioners are being used to help reduce
that shortage (Weaver et al., 2014). Rural communities also have higher age-adjusted death rates
than urban communities, which contribute to increasing illness and premature death due to lack
of resources (Hewitt et al., 2019). There is currently a gap in PHC for older adults who live in
rural communities and the measures to reduce barriers to accessing care. This gap is
demonstrated by the lack of access for older adults to “safe, effective, timely, equitable, and
patient-centered care” (Hewitt et al., 2019, p. 128). Cost-effective quality PHC services are in
demand due to rising patient expectations, and the number of chronically ill and aging
populations (Auerhahn et al., 2012). Therefore, nurse practitioners may have the opportunity to

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improve access to high-quality PHC across the continuum of care (Prasad et al., 2014). Thus, it is
important to evaluate how nurse practitioners could reduce the barriers older adults face with
accessing adequate healthcare in Canada.
The purpose of this integrative review is to identify barriers encountered by older adults
in rural communities that limit access to PHC services and to evaluate strategies that nurse
practitioners can implement to reduce those barriers. This review will be guided by the research
question: How can nurse practitioners working in rural communities reduce the barriers to access
PHC services for older adults?

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Chapter II: Background and Context
Like many other nations worldwide, Canada has an aging population (Statistics Canada,
2016). According to the 2016 census, 16.9% of the population are 65 years and over, while 2.2%
are 85 years and over. This proportion is projected to increase to 6.8 million persons aged 65
years and older in 2020 and will account for 25% of Canada’s population by 2036 (Shah et al.,
2019; Statistics Canada, 2016). The increased life expectancy of Canadians is related to
improved living conditions and the advances made in health promotion, illness prevention, and
treatment options (Statistics Canada, 2016). However, this rise in the aging population also has
considerable implications for the health of Canadians and the healthcare services they will need
in the future. For instance, as people age, more healthcare services are needed. These services
include supporting the aging population through programs, a comprehensive continuum of health
services, and promoting healthy aging (Canadian Medical Association [CMA], 2013). Promotion
of programs and healthy aging include physical activity, injury prevention, nutrition, and mental
health (CMA, 2013). A continuum of health services incorporates delivering high-quality care
for all aspects of older adult’s health, such as community-based healthcare, home care, and longterm and palliative care (CMA, 2013). This continuum makes it easier for older adults to stay at
home as long as possible and transition smoothly to another level of care when indicated (CMA,
2013). Therefore, older adults (persons aged 65 years and older) may require a more diverse
approach to their healthcare that involves multiple disciplines collaborating through an
interdisciplinary approach. Currently, Canada is prioritizing this approach by shifting from solo
family physician practices to developing new models of PHC (Heale et al., 2018).
As the demographic of Canada changes, its shift has major impacts on the healthcare
system (Shah et al., 2019). For example, adults aged 65-years and older visit their PHC provider

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more than 3-times as often as adults and children under 18 (Shah et al., 2019). Therefore, as the
population ages, the healthcare system must be prepared to predict the needs of older adults to
prevent excess strain on the system while providing adequate access to care. Further, older adults
are living longer, and as their population grows, there is a predicted increase in the “incidence
and prevalence of chronic illnesses and multiple comorbidities” (Auerhahn et al., 2012, p. 193).
Nearly 75% of Canadians aged 65-years and older have at least one chronic condition (CMA,
2013). With higher rates of chronic illnesses, older adults will need access to appropriate
healthcare services, including PHC. Poor access to PHC services is associated with higher levels
of chronic disease, consumption of more medication, and shorter life expectancy (Shah et al.,
2019). However, variability has been noted with the access to PHC in older adults in rural
communities. For example, older, rural individuals have reduced access to care due to multiple
factors, including geographic isolation, poor transport availability, and the association with
deprivation (Ford et al., 2015). Other issues with the access of PHC include the lack of
appropriate support networks for older adults’ families, budgetary constraints from the healthcare
system, and the lack of a range of knowledge-based, social, language, or practical skills (Kurpas
et al., 2018).
This chapter will identify and define the central concepts including nurse practitioners,
older adults, PHC, and rural communities. This chapter will also explore access to PHC, barriers
that older adults face regarding access to PHC in rural communities and nurse practitioners’ roles
as PHC providers to older adults.
Concepts
Nurse Practitioners. Nurse practitioners are healthcare professionals who work in
advanced practice roles to meet the complex health needs of patients in a wide variety of settings

5
(Canadian Nurses Association [CNA], 2019). These advanced practice roles include
autonomously diagnosing, ordering, and interpreting diagnostic tests and prescribing
pharmaceuticals within the nurse practitioner scope of practice (CNA, 2019). Nurse practitioners
act as key contributors to PHC services in many Canadian communities (Auerhahn et al., 2012).
They provide care and management for complex clients with multiple co-morbidities, often
vulnerable populations such as older adults (Hungerford et al., 2016). In many parts of the world,
nurse practitioners provide PHC to patients in rural communities (Auerhahn et al., 2012).
Shortages of PHC providers is a common issue throughout Canadian rural communities, and
nurse practitioners are being implemented into these communities to help reduce that shortage
(Peckham et al., 2018; Weaver et al., 2014). Nurse practitioners also play a major role in the
development of organizational and community programs, quality improvement, interprofessional
collaboration, capacity building, and the advancement of health policies (CNA, 2019).
Older Adults. The term older adult has been used interchangeably in other sources with
elderly, older people/person, and senior (Falkenstern et al., 2005; Ford et al., 2018; Statistics
Canada, 2016). In Canada, the term senior can indicate a person who is 65 years or older and is
generally used in institutional referents such as government, programs, portfolios, and
entitlements (Taylor, 2011). Therefore, aging is often measured by chronological age; however,
the aging process is not uniform due to differences in genetics, lifestyle, and overall health
(Rural Ontario Institute [ROI], 2019). According to the World Health Organization’s (WHO,
2015) World Report on Aging and Health, aging can occur at a biological level, leading to a
decrease in physiological reserves, which puts an individual at an increased risk for many
chronic diseases, including a decline in their capacity. Despite these biological changes, aging
can shift an individual’s role and social position, leading to new roles, viewpoints, and

6
interrelated social contexts (WHO, 2015). Many older adults are also discussed as having
chronic conditions, yet this is not always the case. Therefore, older adults will be addressed as
individuals 65 years and older who may or may not have chronic conditions for this integrative
review.
Primary Health Care. Primary health care is a principle-based, comprehensive approach
which focuses on how services are delivered across the lifespan and the continuum of care in all
settings (CNA, 2015). In North America, PHC is often confused with primary care due to a lack
of conceptual clarity. Primary health care and primary care are used interchangeably throughout
the literature; however, primary care refers to delivering community-based clinical health care
services on an individual level (CNA, 2015). The focus of PHC includes multiple factors that
determine a population’s health and the importance of ongoing care to implement health
promotion strategies in the prevention of chronic diseases and injuries (CNA, 2015). Primary
health care has also been discussed as the health system level that provides the first point of
access to healthcare services (Government of Canada, 2012; Shah et al., 2019). These health care
services can include preventative measures, such as screening, health checks, and chronic disease
monitoring, focusing on providing patient-specific care over time (Ford et al., 2018; Shah et al.,
2019).
Rural Communities. Rural is “of or relating to the country, country people or life, or
agriculture” (Miriam-Webster, 2020). In comparison, a community is “a unified body of
individuals with common interests living in a particular area” (Miriam-Webster, 2020). Rural
communities are areas outside of population centers in which the population densities and living
conditions can vary greatly (Statistics Canada, 2016). Population centers are defined as areas
with a population of at least 1,000 and a density of 400 or more people per square kilometre.

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They can be divided into three groups, with small population centres ranging of a population
between 1,000 and 29, 999, medium populations centres with a population between 30,000 and
99,999, and large urban population centres of a population 100,000 and over (Statistics Canada,
2016). Therefore, rural areas include all territory outside population centres (Statistics Canada,
2016). International organizations and government agencies have attempted to standardize the
definition of rural. For instance, the rural location can be outside the city limits or boundaries of
a town. There can be natural amenities, agricultural development, limited infrastructure, and
limited industrial development (MacGregor-Fors & Vázquez, 2020). In the context of this
integrative review, rural communities are areas outside of urban or highly populated centres.
Access to Primary Health Care
Access to PHC is a multi-factorial concept related to an individual or community’s access
to the medical care system. The degree of access to PHC services can be connected to the
population accessing services and the location of the services. The concept of access is complex
as an individual may have good access but may never need to use a service (Ford et al., 2015).
Therefore, many have argued that the concept of access is not linear and depends on the balance
between the health service need and the health service use (Ford et al., 2015). For instance, the
term access is “the ease with which a person can obtain needed care from the practitioner of
choice within a time frame appropriate to the urgency of the problem” (Premji et al., 2018, p.
214). Access to PHC also involves the availability of a PHC provider and a multidisciplinary
team. Therefore, depending on the location of a population accessing these services may be
challenging.
In Canada, approximately 15% of the rural population is 65 years and older
(Saskatchewan Population Health and Evaluation Research Unit [SPHERU], 2018). Rural areas

8
and people are often considered under-serviced and lack the full range of public services such as
PHC, education, and community support (ROI, 2019). This lack of public services can also
include the deprivation of public infrastructure, most recently with technological services, crucial
for social and economic development across Canada (ROI, 2019). Research has also found that
older adults living in rural communities are at risk of poor access and often have higher health
needs, higher risk for mental illness, and more chronic disease than urban seniors (Ford et al.,
2018; SPHERU, 2018). Within the older adult population, there is an increase of chronic
comorbid conditions. These comorbidities are related to elevated rates of accessing PHC services
and multiple specialist visits (Kurpas et al., 2018).
The CMA (2013) discusses policies to improve access to PHC for older adults in Canada.
They discuss that all levels of government should be involved in programs and supports to
promote healthy aging, an environment and society that is supportive of an aging society, and
healthcare services which provide optimal care and support to older Canadians (CMA, 2013).
Although government policies and strategies are in place to improve Canadian’s access to PHC
services, especially vulnerable populations such as older adults, there has been little
improvement over the last two decades (Premji et al., 2018).
In Canada, each province has separate policies in place for PHC. For instance, in British
Columbia (BC), the PHC policy aims to achieve patient-centred, integrated, comprehensive, and
high-quality care (Peckham et al., 2018). The Ministry of Health of British Columbia discusses
two priorities: interprofessional teams as a focus of the primary and community care system and
to strengthen collaboration between specialists and PHC providers (Peckham et al., 2018). Most
provinces have shifted towards a similar approach that focuses on developing interprofessional
teams to provide access to PHC services. Areas such as Manitoba, Ontario, Nova Scotia, Alberta,

9
Newfoundland and Labrador, and New Brunswick have developed these interdisciplinary teams
(Peckham et al., 2018). These teams consist of physicians, nurse practitioners, physiotherapists,
registered nurses, occupational therapists, mental health counsellors, etc., to improve access and
effectiveness of PHC services (Peckham et al., 2018). Provinces that differ from this approach
include Prince Edward Island, Quebec, Nunavut, and the Northwest Territories (NWT)
(Peckham et al., 2018). In the NWT and Nunavut, Community Health Centres exist which
provide most of the PHC services. In Nunavut, these centres are led by registered nurses, while
physicians provide support remotely or visit communities periodically. In most of the NWT,
nurse practitioners and registered nurses are the main PHC providers, with family physicians
working primarily in hospitals (Peckham et al., 2018).
Although rural areas are often considered to be underserviced, these communities consist
of deep interpersonal ties and share a sense of community (ROI, 2019). For example, rural
communities can include various policy, social and personal factors that contribute to the
meaning of community essence (ROI, 2019). Therefore, older adults may function well in their
home/community but lack access to appropriate services. This lack of access is where rural
communities may struggle to provide suitable environments for older adults, given the limited
healthcare services that often exist (ROI, 2019). However, it is essential to discuss that although
rural communities often are lacking access to healthcare services, older adults may thrive in
other ways such as through a support system of friends and family, walkability to basic services
in the community, and the feeling of establishment (ROI, 2019).
Barriers to Accessing Primary Health Care
To fully understand the barriers that older adults face when accessing PHC services, it is
vital to understand the factors involved with access and how they may interfere with accessing

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PHC services. According to the Council of Ontario Universities (2013), there are five barriers to
accessibility; however, to organize this integrative review, barriers most related to older adults
were chosen and divided into three broad categories: environmental, systemic, and individual
barriers. Environmental barriers can include the natural or built environment that could somehow
impede or prevent an individual from accessing PHC (Council of Ontario Universities, 2013).
Systemic barriers can consist of policies, practices, and procedures that result in individuals or a
population receiving unequal access (Council of Ontario Universities, 2013). Further, individual
barriers for older adults accessing PHC services can include behaviour, perceptions, and
technology for this review.
Environmental Barriers. Access to PHC services can be inversely associated with the
distance or travel time in which people within certain areas are located. In Canada, 20% of the
population lives in rural communities (Weil et al., 2018). Living in rural communities, older
adults are at a higher risk of physical impairment and mobility concerns than non-rural older
adults (Weil et al., 2018). Many of these rural and remote communities lack access to basic PHC
services due to a shortage of healthcare providers (Shah et al., 2019). Older adults living in rural
communities are frequently unable to access healthcare quickly or efficiently (Hewitt et al.,
2019). This inability to access the proper PHC services may lead to improper utilization of
emergency departments, or not seeking care at all (Hewitt et al., 2019).
Additionally, older adults in rural communities may forego routine preventative exams
and screening for preventable or treatable conditions due to inaccessibility of these services
(Hewitt et al., 2019). Due to the inaccessibility of many PHC services, older adults may not be
able to remain in their homes and community (ROI, 2019). Therefore, geographic location
becomes a primary barrier for access to healthcare services due to rural areas which struggle to

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provide appropriate environments for older adults to age well in their own home/community
(ROI, 2019).
Systemic Barriers. Many older adults face inadequate access to PHC providers in rural
communities in Canada (Shah et al., 2017, 2019). This unequal healthcare provider distribution
and increasing service needs of older adults and the aging population, especially those with
chronic conditions, can result in poorer health, shorter life expectancy and higher rates of
disability (Shah et al., 2017). Multiple factors contribute to the shortage of healthcare providers.
These factors include the retirement of practicing providers, the inability to accept new patients
by aging providers seeking to reduce their workload, difficulty in recruiting and retaining new
providers to rural areas, and fewer medical students who are pursuing family practice careers
(Hewitt et al., 2019). These factors inadvertently leave a smaller number of physicians to serve
and practice in rural communities.
Other systemic factors that are barriers for older adults accessing PHC services include
the lack of communication and collaboration between healthcare providers, which subsequently
affects experiences of care and patient outcomes (Kurpas et al., 2018). This lack of
communication and collaboration is between PHC providers and specialists, nurse practitioners
and physicians, and other interdisciplinary team members (Ford et al., 2015). In a survey by
Weaver et al. (2014), 6% of respondents, most of whom were older adults, reported that allied
health professionals were involved in the treating their chronic conditions. The adverse outcomes
that have resulted from these barriers include delayed care, forgone care, or no preventative care
in the past year (Hewitt et al., 2019).
Individual Barriers. With the world changing and technology becoming more relied
upon by the healthcare system, older adults may not have the skills, and the desire to adapt to

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service changes (Ford et al., 2018). Information and communication technologies provide an
opportunity to improve rural healthcare delivery for older adults, and therefore older adults are
the fastest-growing user group of technology (Batsis et al., 2019). For example, the development
of high-speed internet in rural locations provides areas with telemedicine delivery, which was not
feasible ten to twenty years ago (Batsis et al., 2019). This development has made virtual
healthcare services more accessible for rural communities. However, older adults have less
experience with emerging technologies (Batsis et al., 2019). They also have considerable
sensory, memory, and other aging-related barriers to engage in telehealth or telemedicine
services offered for many rural individuals (Batsis et al., 2019). Technology barriers can include
video-conferencing services, and new appointment systems put in place at PHC clinics (Batsis et
al., 2019; Ford et al., 2018). Fine-motor eye-hand coordination issues contributed to the videoconferencing service barriers (Foster & Sethares, 2014). New appointment systems, such as
automated voice messaging machines, were another barrier that older adults faced with
technology services (Ford et al., 2018).
Older adults, like other populations, have perceptions of how the healthcare system
functions in Canada. For many older adults, these social norms or perceptions have led to the
belief that PHC providers will make special provisions if they are unwell, as they do not
unnecessarily access the system (Ford et al., 2018). However, accessibility or availability of
these services is not always an option leading to frustration and lack of seeking PHC after having
a poor experience (Kurpas et al., 2018). Thus, individual barriers noted by older adults in
multiple studies were the breach of a social contract or not wanting to access PHC services due
to feeling that their concerns were not likely to be heard or that they may be regarded as minor
issues (Ford et al., 2018; Hewitt et al., 2019).

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Nurse Practitioners as Primary Health Care Providers
According to the Canadian Nurses Association (CNA, 2019), 6,159 nurse practitioners
are working throughout Canada. Over 3 million Canadians receive their health care from a nurse
practitioner, with 93% of Canadians reporting that a nurse practitioner can meet their day-to-day
health needs as their PHC provider (CNA, 2019). Around one-third of nurse practitioners in
Canada work in hospitals, while two-thirds work in community or PHC or long-term care
facilities (CNA, 2019). The role of the nurse practitioner was initially developed in response to
an anticipated shortage of PHC providers (Grant et al., 2017). Nurse practitioner roles were
implemented to improve access to PHC, especially for underserved and vulnerable populations,
and enhance PHC providers and teams (Grant et al., 2017). However, as each province
developed legislation expanding the nurse practitioners’ scope of practice, many provinces have
nurse practitioners in specialized areas. These specialized areas include pediatrics, neonatology,
oncology, heart failure clinics, mobile clinics, internal medicine, emergency departments, etc.
(Alden-Bugden, 2019; Marceau et al., 2020). Each year, the number of nurse practitioners grows
and as does their role in the provision of PHC services (Grant et al., 2017).
As the population aged 65 years and older continues to increase, older adults will
comprise a large portion of nurse practitioner caseloads. These caseloads will contribute both to
PHC settings and acute care settings as the hospitalization rate for adults aged 65 and over is
more than three times versus adults under 65 years (Auerhahn et al., 2012). In addition, multiple
physical, cognitive, and functional comorbidities requiring complex interventions lead to
increased length of stay and higher risk for complications in many hospitalized older adults
(Auerhahn et al., 2012). Thus, nurse practitioners may provide opportunity for improving access
to high-quality, cost-effective PHC across the continuum of care, specifically for older adults

14
(Prasad et al., 2014). Their role in providing clinical care and education, supporting prevention,
health, and wellness, and using evidence-based practice is necessary to the management of
complex patients with chronic conditions (Prasad et al., 2014). Therefore, with the population of
older adults seen with chronic diseases and the nurse practitioner’s ability to care for this
population competently, there has been support and implementation of the nurse practitioner role
to improve health outcomes, functional status, and quality of life (Grant et al., 2017; Prasad et
al., 2014).

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Chapter III: Methods
A comprehensive search of the literature was completed to explore the research question:
How can nurse practitioners working in rural communities reduce the barriers to access PHC
services for older adults? The research question was developed through the Population,
Intervention, and Outcome (PIO) format to guide the search (Gray et al., 2017). The University
of Northern British Columbia’s online library services were utilized for this literature search. The
electronic databases CINAHL, PubMed, MEDLINE (Ovid), and PsycINFO were searched in
September 2020. These databases were selected due to their relevance in nursing literature, allied
health disciples, and nursing specialities (University of Northern British Columbia, n.d.).
Keyword search terms and medical subject headings (MeSH) related to the research question
included the search terms: nurse practitioner, rural community, access, primary health care, and
older adult (see Tables 1 & 2).
Search Strategies
An initial search was conducted to ensure that the relevant keywords and MeSH terms
selected for this literature search were appropriate. In addition, a table was created to include
important concepts that would guide the research strategies (see Table 3). Relevant keywords
and MeSH terms were used to create a primary search strategy which was then adapted and
applied to each database (see Table 4). The search was discussed with a university librarian to
include the most applicable subject headings and keyword strategies for this integrative review.
Inclusion and Exclusion Criteria
Inclusion and exclusion criteria were applied to the search to narrow down the literature
results further (see Table 5). Interventions that determined how nurse practitioners can provide
access to PHC in rural communities for older adults were included to demonstrate how nurse

16
practitioners can approach these barriers to access and implement them into practice. Studies that
discussed barriers older adults face to accessing PHC were also chosen, as barriers are essential
for nurse practitioners to understand and identify to create change and improve access. The
exclusion criteria were non-peer reviewed sources, and articles written in a non-English
language. The date range of articles was left open as the available literature on access to care for
older adults is limited. Therefore, it was important to broaden the search results and include all
relevant literature. Articles were included if the study addressed models of healthcare or nurse
practitioner-led models which focus on access to PHC in rural communities. Articles were
excluded if the title and abstract did not apply to accessing PHC services or to the potential role
nurse practitioners have in rural communities regarding access.
Table 5
Inclusion and Exclusion Criteria of Literature Search

Inclusion

Exclusion

Nurse practitioners

Published in non-English language

Rural settings

Non-peer reviewed literature

Older adults
Interventions/Tools
Primary health care setting
Barriers to accessing primary health care

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Search Results
The total search produced 158 articles, which were exported into the citation manager
Zotero. After duplicates were removed, 129 articles remained. Abstracts and titles were searched
for relevance, and limits were applied to the articles as part of the inclusion and exclusion
criteria; 98 items were removed. After the exclusion of irrelevant articles, a total of 31 articles
were left. Each article was read to determine applicability to the research question. Additionally,
reference lists were searched, and 3 articles were added due to their pertinence to the research
question. Lastly, a forward search of each article was completed for an additional 5 articles.
Eighteen articles were included for the final number in the literature search. See Figure 1 for the
complete literature search flow diagram.

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Chapter IV: Findings
The framework that guided this literature analysis were the appraisal tools found in
Davies and Logan (2018), the Critical Appraisal Skills Programme ([CASP], n.d.), and Hoffman
et al. (2017). These appraisal tools provided structure for the critical appraisal of systematic
reviews, mixed-methods studies, qualitative, and quantitative studies and further provided insight
on the quality of the literature. Pertinent information relevant to the research question guiding
this review was obtained and will be discussed using themes.
The final search of the literature resulted in a total of 18 articles (see Appendix A). Most
of the articles were published in Canada (n=8) and the United States (n=4). Two articles were
published in Australia, two in the United Kingdom, one in South Africa, and one included the
countries Canada, the Netherlands, the United States, the United Kingdom, Slovenia, Guam, and
Australia. The articles in the literature matrix ranged in dates from 2005 to 2019. The largest
number of articles were published in 2019 (n=6), then 2018 (n=3), and lastly 2016 (n=4). One
article was published in the year 2014, 2008, and 2005, while two articles were published in
2017. The literature was comprised of nine quantitative studies, three mixed-methods studies,
three qualitative studies, and three systematic reviews.
To effectively reduce barriers to older adults’ access of PHC services in rural
communities, nurse practitioners working in rural communities must recognize these barriers. In
the literature, sixteen of the eighteen articles discussed barriers to access of PHC services (Batsis
et al., 2019; Bresick et al., 2016; Clare, 2019; Dolovich et al., 2019; Ford et al., 2018, 2019;
Heale et al., 2018; Hewitt et al., 2019; Hungerford et al., 2016; Hunter et al., 2016; Prasad et al.,
2014; Ross et al., 2016; Shah et al., 2017, 2019; Wakerman et al., 2008; Weil et al., 2018).
Although barriers will not be examined as a main theme in this review, relevant barriers will be

19
explored throughout each theme. This is important for nurse practitioners to gain an
understanding of the barriers that prevent older adults from accessing PHC services to improve
access for this population.
Three main themes arose from the review of literature in the literature review matrix.
These themes included virtual care, an interdisciplinary approach among PHC teams, and the
implementation of nurse-practitioner models of care. The articles contained in this review
focused on virtual care in terms of telemedicine and telehealth, interdisciplinary teams, which
included the importance of role clarification among team members, and nurse practitioner-led
models of care that incorporated home visits. The following sections will address these identified
themes.
Virtual Care
Virtual care is a broad term that can include mobile services for patients with the use of
video technology or mobile-based technology to access PHC services through a provider (Batsis
et al., 2019; Clare, 2019; Ross et al., 2016; Wakerman et al., 2008). The literature can use
telemedicine and telehealth interchangeably to describe virtual care. Telemedicine and telehealth
services will be examined, including the barriers that these services can reduce for older adults
accessing PHC services in rural communities when applied by nurse practitioners.
Telemedicine and Telehealth. Four of the eighteen articles included in the literature
review discussed the delivery of telemedicine or telehealth programs as a strategy for improving
access to PHC services in rural communities (Batsis et al., 2019; Clare, 2019; Ross et al., 2016;
Wakerman et al., 2008). Telemedicine and telehealth programs included videoconferencing
using desktop computers, laptops, tablets, and smartphones (Batsis et al., 2019). These services
can also include virtual appointments made over the phone without the use of a video system

20
(Clare, 2019). Telemedicine and telehealth can be used to increase access to and sustain service
for communities too small to support discrete rural service (Wakerman et al., 2008). This
increase in access is essential for improving access to health services for widely dispersed and
isolated populations and by providing access to PHC while overcoming the shortage of PHC
providers (Batsis et al., 2019; Wakerman et al., 2008).
Improvements seen with the implementation of telemedicine programs in an older adult
population include improved cognitive function and improvements in fall, exercise, and strengthbased measurement (Batsis et al., 2019). Other developments include ease of access and time to
see a provider. For instance, a telehealth video technology program implemented in a rural,
northern community in Alberta found all members who accessed this service felt the wait time
was appropriate (Ross et al., 2016). Participants also reported they were able to understand the
provider and would use the service again (Ross et al., 2016). The use of virtual outreach services,
such as telehealth, has also shown improved access to records, reduced physician on-call hours,
and increased the use of consultation hours (Wakerman et al., 2008). Therefore, access to PHC
services and the lack of healthcare providers in rural and remote areas are barriers that telehealth
and telemedicine have helped overcome (Wakerman et al., 2008).
Ten of the eighteen articles in the review of literature highlighted that environmental
barriers such as rural and remote locations pose as a barrier for older adults accessing PHC
services (Batsis et al., 2019; Ford et al. 2018, 2019; Hewitt et al., 2019; Hungerford et al., 2016;
Ross et al., 2016; Shah et al., 2017, 2019; Wakerman et al., 2008; Weil et al., 2018). Thus, the
location in which older adults reside as a barrier to accessing PHC services is evident in the
literature. Further, the literature showed inequities in distributing PHC services across Alberta,
Saskatchewan, and South Western Ontario (Shah et al., 2017, 2019). Nurse practitioners in

21
Alberta and Saskatchewan demonstrated lower access scores per 10,000 people; however, there
was no significant correlation between a general practitioner and nurse practitioner access scores
in both provinces (Shah et al., 2017). The findings demonstrated that nurse practitioners may
address gaps in areas with poor access (Shah et al., 2017). Therefore, as nurse practitioners are
practicing in many rural communities in Canada, the need to identify barriers relevant to older
adults and if nurse practitioners can implement telemedicine and telehealth programs to improve
access is important (Batsis et al., 2019; Ross et al., 2016).
The literature found remote and rural locations demonstrated higher rates of chronic
conditions by individuals due to fewer transportation options, either from older adults not having
a vehicle or license or a family member/support person to drive them to and from appointments
(Batsis et al., 2019; Ford et al., 2018). This inaccessibility to transportation prevented many older
adults in rural communities from accessing PHC services. Similarly, Ford et al. (2019) found that
the transportation costs vs. transportation access were more of a barrier faced by older adults to
accessing PHC services. Transportation costs range from the lack of funds to purchase and
maintain a vehicle, or service a taxi transportation service (Ford et al., 2019).
Four studies in the literature review discussed telehealth and telemedicine programs; each
article discussed them differently. For example, in the systematic review by Batsis et al. (2019),
the authors looked at studies which used all intervention-based groups and synchronous video
conferencing modalities. These devices ranged from video conferencing with a pan-tilt-zoom
camera and handheld medical camera systems to video-conferencing-enabled personal
computers and peripherals to computers with web cameras and microphones (Batsis et al., 2019).
These devices were all under the telemedicine model with the patient on the receiving end and a
specialist, physician, nurse practitioner, or other interdisciplinary team members on the

22
transmitting end (Batsis et al., 2019). The video contact ranged from monthly to three times per
week. Therefore, the modality of service in these studies consisted of a device (laptop, tablet,
computer, cellphone) that provided video via a camera to connect the patient with the healthcare
professional (Batsis et al., 2019).
In another approach, a telehealth program developed in Northern Alberta included a
space to house telehealth equipment in the community (Ross et al., 2016). The PHC clinic
offered a private consultation space for PHC providers and had a licensed practical nurse (LPN)
who worked at the clinic and was responsible for screening patients requesting telehealth
appointments. The LPN would screen patients through the list of patient’s symptoms and
conditions (Ross et al., 2016). Walk-in patients were also accepted and filtered by the LPN. The
provider was able to have complete control of the high-resolution camera, allowing them to
manipulate the camera and image for the physical assessment (Ross et al., 2016). The clinic also
provided a digital stethoscope and a noise-cancelling headset so that the provider could listen to
the patient’s lungs and heart (Ross et al., 2016).
Clare’s (2019) pilot project offered nurse practitioner services, including comprehensive
physicals, screening for disease, prescribing, referrals, health promotion counselling, treatment
of acute and chronic conditions, and prevention strategies. These services were all offered either
in the home or the office environment, depending on the client’s choice. Telehealth services
included were described as video, email, or phone options (Clare, 2019). A nurse practitioner
would be available 24/7 through rotated on-call schedules and house calls on weekdays from 10
am to 7 pm (Clare, 2019). The pilot project provided nurse practitioners with a laptop, and portal
printer-fax machine for house calls and appropriate tools such as portable weigh scale for
assessments (Clare, 2019).

23
Lastly, Wakerman et al. (2008) discussed multiple health service models that are
reviewed in the next section. One of these service models included virtual outreach services such
as telehealth. Virtual outreach services address the health needs of communities with populations
too small to support permanent local services by providing access through virtual or periodic
visiting services (Wakerman et al., 2008, p. 7). Thus, instead of discussing a specific program
and incorporating it into a study, Wakerman et al. (2008) looked at the which models of care
would be more appropriate for population size of a community. The authors also examined if
governments implemented these models appropriately into smaller communities, how it could
improve access for residents. Within the literature that discussed virtual care, there was no one
specific approach that was given for nurse practitioners or PHC providers to follow.
Integrating Nurse Practitioner-Models of Care
Models of care provide a framework that includes a theoretical basis, standards,
evidence-based practices, key performance indicators and measurable outcomes (Hungerford et
al., 2016; Wakerman et al., 2008). These models of care can be nurse practitioner-focused,
guiding the work of nurse practitioners. For instance, models of practice that include nurse
practitioners or nurses can manage or organize interdisciplinary teams (Prasad et al., 2014). This
organization is relevant when providing care to populations across various settings to develop
proactive approaches for multidisciplinary team members and nurse practitioners (Hungerford et
al., 2016; Prasad et al., 2014; Wakerman et al., 2008). In the literature, nurse practitioner models
of care included a nurse practitioner who has competencies in PHC, related to assessments,
diagnoses, and treatment of acute, emergent, and chronic conditions (Prasad et al., 2014). The
inclusion of a nurse practitioner supports communities and populations such as older adults to
provide flexibility in multiple settings for adaptation. Nurse practitioner models of care can also

24
provide more proactive approaches for healthcare providers, reduced interdisciplinary conflict
through awareness of other roles, and a shared understanding of outcomes (Hungerford et al.,
2016).
Three out of eighteen articles discussed the importance of implementing a model of care
that considers the PHC provider, population, and community in the literature (Hungerford et al.,
2016; Prasad et al., 2014; Wakerman et al., 2008). For example, the study by Hungerford et al.
(2016) created an aged-care nurse practitioner model which targeted the needs and preferences of
the aging demographic in rural and remote communities in Australia. These needs and
preferences included ongoing management of acute and chronic conditions, comprehensive
health assessments, prescriptions, advice, and development of health management plans and
referrals when necessary (Hungerford et al., 2016). The study by Prasad et al. (2014)
implemented a nurse-practitioner model of care that integrated a nurse practitioner with extra
geriatric training/education. The nurse practitioner was to act as a collaborator between various
partners such as family members, long-term care staff, home care services, various community
organizations, and family physicians.
Lastly, the authors discussed multiple models of care to determine the best service
options for rural and remote communities in Australia (Wakerman et al. 2008). These models
included discrete, integrated, and outreach/virtual outreach models of care. Discrete service
models provide PHC to communities with a rural population or communities characterized by
larger, more closely settled communities (Wakerman et al., 2008). Services offered included
walk-in clinics and university clinics. Their purpose was to sustain a primary care provider in
rural and larger remote communities with difficulties retaining providers (Wakerman et al.,
2008). Integrated service models focus on improved access to services and involve coordination

25
between access to services that are not otherwise available locally. These models are useful in
communities that are smaller and more isolated to reduce the need for patients to travel and
maximize the range of locally available services (Wakerman et al., 2008). Outreach/virtual
outreach service models, which the writer discussed previously, addressed populations too small
to support permanent local services by providing access through virtual or periodic visiting
services (Wakerman et al., 2008).
Clearly defined models, specifically nursing models of practice, provide a framework for
healthcare providers and systems (Hungerford et al., 2016; Wakerman et al., 2008). The
literature showed models of care to offer pre-existing structures for clinical governance and
general management and funding (Wakerman et al., 2008). Models of care can also improve
collaborative agreements negotiated at a systemic level between the nurse practitioner, other
health professionals, and various service providers (Wakerman et al., 2008). Models of care that
focus on nurse practitioners have been used to manage or organize teams, thereby meeting the
needs of patients (Hungerford et al., 2016). The benefits of a well-implemented model included
the development of proactive approaches for healthcare teams, higher personal value of
healthcare providers, and the improvement of interdisciplinary teamwork (Hungerford et al.,
2016). Well-functioning interdisciplinary teams can lead to reduced interdisciplinary conflict and
improved outcomes for patients due to shared goals and enhanced continuity of care (Hungerford
et al., 2016).
The lack of adequate PHC resources for rural communities was the most common
systemic barrier indicated in the literature (Batsis et al., 2019; Ford et al., 2018; Hewitt et al.,
2019; Shah et al., 2017; Wakerman et al., 2008; Weil et al., 2018). For example, the lack of
adequate PHC resources included the shortage of permanent PHC providers in rural

26
communities, no after-hour or weekend clinics for patients to access, shortages of clinic staff,
lack of geriatric specialists, and high patient-to-practitioner ratio. This lack of PHC resources
reduces the access to health and preventative services for rural older adults (Ford et al., 2018;
Hewitt et al., 2019; Weil et al., 2018). Further, the literature noted that with the increasing strain
and demand on PHC services, national and regional policies have begun to add more pressure to
the delivery of services, thereby limiting these services to disadvantaged older adults (Ford et al.,
2018). The delivery of services included the time providers are taking with each appointment,
leading to primary care providers doing more without the necessary resources (Ford et al., 2018).
Older adults in rural Canadian communities also discussed feeling anxious about the lack of
healthcare in their communities and have thought about moving to another area to live closer to a
hospital with specialists and resources (Hewitt et al., 2019).
In rural communities, a model with characteristics that captures population aggregation to
support minimum services threshold requirements while ensuring adequate access to care is
crucial (Wakerman et al., 2008). For example, remote locations need virtual outreach models,
whereas rural communities do well with discrete and integrated PHC models (Wakerman et al.,
2008). Nurse practitioner-led transitional care models that support frail older adults transitioning
between health sectors with the provision of follow-up care, education, self-management
support, and medication review have also found better outcomes and lower healthcare costs
(Prasad et al., 2014). Nurse practitioner-led models of “dementia care have led to better behavior
management and caregiver support, and those related to chronic disease management have been
associated with better health outcomes and less hospitalizations” (Prasad et al., 2014, p. 1773).
The literature also emphasized socioeconomic factors, which serve as systemic barriers
for older adults’ accessing PHC services (Batsis et al., 2019; Bresick et al., 2016; Shah et al.,

27
2019). Socio-demographic factors such as unemployment, educational level, and type of
dwelling may add to the complexity and challenge of providing PHC to communities where
these issues are prevalent (Bresick et al., 2016). System-specific factors related to coverage and
financial barriers were also other common socioeconomic factors that may prevent older adults
from accessing PHC services (Heale et al., 2018; Hewitt et al., 2019). For instance, older adults
may not always have the financial and social supports required to implement the treatment plans
for their conditions. They may also not be able to afford medications, devices, or even
appropriate food (Heale et al., 2018). On a systemic level, a nurse practitioner-led model of care
program implemented by Prasad et al. (2014) had expected short-term outcomes of enhanced
care coordination and integration within the community. Appropriate referral to community
resources gave older adults increased system navigation support, improved awareness of
available supports and resources, enhanced linkages with community support services, and easier
access to these community support services (Prasad et al., 2014).
Home Visits. Home visits were an intervention strategy completed by the nurse
practitioner to improve access to PHC services (Clare, 2019). In the project developed by Clare
(2019), the nurse practitioner’s role included managing video appointments and telephone calls
when appropriate and attending appointments at the patient’s home if they were unable to travel.
However, challenges that arose with home visits included the obligations to provide efficient,
timely care (Clare, 2019). Timely care was difficult for nurse practitioners to achieve in the
context of professional commitments, especially ensuring privacy and confidentiality when
conducting a video consultation in the car between scheduled home visits or talking with a client
on the phone (Clare, 2019). In a similar program developed by Prasad et al. (2014), a specialized
geriatric nurse practitioner collaborated with PHC providers and a geriatrician to provide

28
coordinated, comprehensive care. This care consisted of supporting older adults as they
transitioned between sectors, including their home, the hospital, and retirement and long-term
care homes (Prasad et al., 2014). The geriatric nurse practitioner would provide follow-up
through home visits if the patients could not come into the clinic due to barriers such as frailty,
location, and lack of transportation (Prasad et al., 2014). Home visits are essential when looking
at what a nurse practitioner-led model of care should incorporate to reduce the barriers older
adults face when accessing PHC services in rural communities (Clare, 2019; Prasad et al., 2014).
In summary, there are multiple models of care are discussed in the literature to address
the lack of access to PHC for older adults. These models of care were discrete, integrated,
outreach/virtual outreach, and nurse practitioner-led models. Models of care can include home
visits provided nurse practitioners, which fall under an outreach model of care, and can be
implemented into rural communities. However, there is an apparent lack of a model that
incorporates all the models discussed in the literature which could reduce barriers to older adults’
access to PHC services in rural communities.
Interdisciplinary Teams
Interdisciplinary teams consist of healthcare professionals within PHC who work
collaboratively together to provide optimal care for the population (Weil et al., 2018). This teambased approach can address complex patients and issues by providing comprehensive care that
enhances each discipline’s practice (Weil et al., 2018). The literature discussed that older adults
often have multiple chronic conditions or comorbidities and need either a specialized approach
with the inclusion of geriatric specialists or interdisciplinary teams (Prasad et al., 2014; Weil et
al., 2018).

29
Interdisciplinary care is essential to improving older adults’ access to PHC services by
nurse practitioners (Prasad et al., 2014). Without interdisciplinary care, nurse practitioners may
have difficulty collaborating with interdisciplinary team members to provide older adults with a
comprehensive approach to care, therefore reducing their access to appropriate PHC services. An
interdisciplinary approach to care has been highlighted in the findings to be an integral part of
reducing barriers to accessing PHC for older adults in rural communities (Bresick et al., 2016;
Heale et al., 2018; Prasad et al., 2014). Interdisciplinary teams were developed in PHC to enable
healthcare providers to manage patients more effectively with chronic conditions, and to provide
a better integration with tertiary care (Prasad et al., 2014). With an interdisciplinary approach,
“there is a more comprehensive provision of information and screening for health promotion,
disease prevention, and early detection guided by epidemiology and the health profile of user
communities” (Bresick et al., 2016, p. 9).
Further, the collaboration between nurse practitioners, geriatricians, and PHC providers
demonstrated a positive effect on the functional status of older adults in hospital, improved their
overall well-being, and reduced hospital admissions and institutionalization (Prasad et al., 2014).
Similarly, there is a more supportive environment with effective interprofessional team
functioning and fewer community referrals because the team is accessible (Heale et al., 2018).
An increased connection between services and patients improves through an integrated system
consisting of a care coordinator or nurse practitioner (Prasad et al., 2014). However, it is
pertinent to understand that while services may be available in PHC, if they do not meet an
acceptable level of performance, issues of accessibility for older adults and PHC services may
still arise (Bresick et al., 2016). Therefore, if the level of performance from the PHC providers or
the service itself is not meeting an acceptable level for patients, older adults may be experiencing

30
a gap in comprehensive care or an interdisciplinary approach limiting their access to PHC
services (Bresick et al., 2016).
As previously discussed, the literature found the collaboration between interdisciplinary
team members, nurse practitioners, and specialists to be an integral aspect of interdisciplinary
care for older adults living in rural communities, leading to improved access to PHC services
(Heale et al., 2018). For example, lack of adequate PHC resources and providers for rural
communities was the most common systemic barrier indicated in the literature (Batsis et al.,
2019; Ford et al., 2018; Hewitt et al., 2019; Shah et al., 2017; Wakerman et al., 2008; Weil et al.,
2018). This lack of PHC providers also consisted of the lack of specialists available for older
adults (Batsis et al., 2019). The absence of geriatricians and geriatric care combined with high
patient-to-practitioner access to health and preventative services for rural older adults is a barrier
for older adults accessing the type of care that may benefit the most (Weil et al., 2018).
Multiple studies indicated that reduced access to PHC providers and health services,
primarily due to the workforce shortage throughout healthcare and the rural location of specific
communities, served as a barrier for older adults (Hewitt et al., 2019; Wakerman et al., 2008).
For instance, the “2014 Canadian Community Healthy Survey reports that three out of ten
provinces determine that the proportion of residents was higher than the national average of
14.9% without regular doctor” (Shah et al., 2017, p. 97). In correlation, patients may choose to
visit the immediate care clinic or emergency care services when they cannot see their PHC
providers due to long wait times or inaccessibility (Hewitt et al., 2019). This use of immediate or
emergency care raises the concern that older adults in Canada may not have access to PHC
providers due to the lack or unavailability of providers in rural communities, therefore putting
strain on the emergency/urgent care settings (Hewitt et al., 2019).

31
The aging population was an individual barrier that arose multiple times in the literature
(Shah et al., 2017; Ford et al., 2019; Weil et al., 2018). Aging has distinct issues and presents
unique situations regarding access to PHC (Weil et al., 2018). As adults age, they require a more
comprehensive approach from PHC providers due to a potential increase or development of
chronic conditions, assessment of activities of daily living, housing, transportation, caregivers,
end of life care, and appropriate community resource linkages (Falkenstern et al., 2005; Ford et
al., 2018; Heale et al., 2018; Hewitt et al., 2019). In the literature, physicians and nurses
consistently responded with higher impact ratings from chronic conditions than older adults
indicating that older adults are not accessing services due to minimization of their chronic
conditions and need for care (Falkenstern et al., 2005). With an interdisciplinary team available
for older adults, this could increase their access to other healthcare roles providing a more
comprehensive approach (Falkenstern et al., 2005).
Dolovich et al. (2019) developed The Health TAPESTRY (Health Teams Advancing
Patient Experience: STRengthening QualitY) intervention program to improve team-based PHC.
This program included interprofessional PHC teams using new in-home technologies and
community engagement to provide a comprehensive approach to care based on patient’s goals,
risks, and needs (Dolovich et al., 2019). Goal examples included physical activity, productivity,
social connection, maintenance of health, and mental health (Dolovich et al., 2019). The study
found that patient-centred primary health care with an interdisciplinary team involvement
improved patient experience measures (Dolovich et al., 2019). This improvement is important
when determining how nurse practitioners can reduce individual barriers, such as the complexity
of aging, to increase older adults’ access to PHC services (Dolovich et al., 2019).

32
Other individual barriers discussed in the literature relating to older adults were language
barriers (Hewitt et al., 2019; Ross et al., 2016), cultural or religious lack of understanding
(Hewitt et al., 2019), and lack of trust in the PHC provider (Hewitt et al., 2019). Interdisciplinary
teams can address these individual barriers by collaborating with a nurse practitioner and having
more members of the team available for older adults to see as providers. In many rural
communities, older adults often have no choice in who their PHC provider is. If they have
concerns or barriers such as language and culture, there are often limited resources to fix this
(Hewitt et al., 2019). There is a comprehensive delivery of care with multiple disciplinary lenses
that can reduce these individual barriers through collaboration and a targeted approach to address
individual needs (Weil et al., 2018). Therefore, when several disciplines collaborate and
contribute to the best practice, interdisciplinary teams can improve access to PHC services (Weil
et al., 2018).
Role Clarification. Role clarification was an important factor that arose multiple times
regarding the interdisciplinary team approach (Heale et al., 2018; Hungerford et al., 2016; Prasad
et al., 2014). When interdisciplinary team members understand each other’s roles, including the
nurse practitioner role, then appropriate referrals and utilization of each member’s skill set can
be accomplished (Heale et al., 2018). Nurse practitioners may have different skillsets and scope
of practice depending on their prior experience or nursing background. Therefore, it was
important for nurse practitioners to clarify their role to the interdisciplinary team members if this
was the first time a nurse practitioner worked with the team (Prasad et al., 2014). For example,
nurse practitioners can be available for home visits; however, it was dependent on which team
member was the most appropriate for the visit. If the practitioner feels as though the patient
would benefit from a different team members’ visit, this could be discussed as an option for

33
registered nurses, registered psychiatric nurses, or social workers within the interdisciplinary
team (Heale et al., 2018). Thus, the literature discussed the need for clarity of roles and
responsibilities and the need to adapt the practice to the specific professional relationships
among team members was discussed to give each team member the opportunity to work to their
full scope. This ability to work to their full scope of practice would make healthcare providers
more accessible to patients and improve their care delivery (Heale et al., 2018; Hungerford et al.,
2016).
Role clarification of nurse practitioners is also important when they are involved in older
adults’ care, and to assess their individual needs. For example, treating older adults as whole and
unique individuals was found in the literature to be pertinent when looking at nurse practitioners
reducing barriers to accessing PHC services for older adults (Hewitt et al., 2019). As previously
discussed, one of the individual barriers faced by older adults included the lack of trust in PHC
providers due to unmet expectations and lack of respect shown to patients by the provider. This
is evident through a study participant stating “I felt totally disrespected. I am in my 80’s, so I
have a few problems and he [PHC provider] didn’t deal with even one of them” (Hewitt et al.,
2019, p. 12). Therefore, the older adult patient felt disrespected due to lack of treatment from the
PHC provider who did not adequately assess their individual, and unique needs. Some nurse
practitioners may have an opportunity to overcome this barrier for older adults’ accessing PHC
services as some can allocate more time with patients during appointments (Heale et al., 2018).
In the study by Heale et al. (2018), authors discussed that nurse practitioner visits are around 30
minutes and potentially longer if the patient has multiple chronic conditions or older adults who
may need more time in the appointment. Thus, nurse practitioners may take the time to address

34
the individualized needs of older adults and clarify their role in the older adult’s plan of care to
provide better access to PHC services for this population (Heale et al., 2018).
Participants discussed that although living in rural communities presents challenges in the
quality of health care services if they had a more permanent, rather than temporary, member of
the community who would spend time listening to them, this would improve their perceived
access to care (Hewitt et al., 2019). Therefore, while nurse practitioners may not be able to solve
diminishing numbers of PHC providers in rural communities across the country on their own,
they can treat each patient as a unique individual to improve their quality of care (Hewitt et al.,
2019).
Other individual barriers that arose in the literature which focused on older adults include
marginalization due to age, feeling like a nuisance, perceived as excluded from services, and that
services are not user-friendly to the elderly (Ford et al., 2018, 2019; Hewitt et al., 2019). Older
adults who also found it challenging to access PHC services discussed a sense of frustration that
the practice breached “social contract” by not recognizing that they seldom utilized services
available (Ford et al., 2018, p. 6). This social contract is described as a set of unwritten rules
perceived by a patient, relating to and based on older adult’s experiences (Ford et al., 2018).
With healthcare providers not recognizing these social contracts, older adults are at risk for not
accessing PHC services.
Additionally, findings discussed that the introduction of the nurse practitioner role
improved access to care in an area short of PHC providers, with 817 previously unattached
patients added to the nurse practitioner’s caseload (Hunter et al., 2016). The nurse practitioner
role also improved access for some complex patients. One participant in a study by Hunter et al.
(2016) described connecting another patient to the NP for PHC services due to difficulty finding

35
a PHC provider and struggling within the health care system. Therefore, with proper role
clarification by the nurse practitioner, there can be improved access to PHC services for older
adults through other interdisciplinary team member’s referrals or community awareness (Hunter
et al., 2016).

36
Chapter V: Discussion
Relevant themes identified through the integrative literature review included virtual care,
nurse-practitioner models of care, and interdisciplinary teams. In the literature, barriers were
highlighted that prevented older adults in rural communities from accessing PHC services. Thus,
nurse practitioners have an opportunity to reduce some of the barriers preventing older adults in
rural communities from accessing PHC services. With virtual care services, the implementation
of nurse-practitioner models of care, and interdisciplinary teamwork, nurse practitioners may
reduce barriers for older adults in rural communities accessing PHC services.
Virtual care, such as telemedicine and telehealth, was discussed in the findings as an
integral part of how nurse practitioners could reduce barriers of geographic isolation in the
context of rural communities whose population must travel to receive specialized care and PHC.
Thus, virtual care demonstrates equivalent outcomes, highlighting the potential for telemedicine
and telehealth to address geographic barriers while delivering positive health outcomes to older
adults (Batsis et al., 2019). Similarly, older adults in the literature were comfortable using
technology to enhance access to care; therefore, nurse practitioners can offer some of these
services, such as virtual appointments using a telephone or a laptop with videoconferencing
(Clare, 2019). Suggestions for nurse practitioners to implement into practice include the
availability of telephone appointments, obtaining telehealth or telemedicine equipment for more
remote locations so the nurse practitioner could assess patients virtually (Batsis et al., 2019;
Clare, 2019; Wakerman et al., 2008). This mode of virtual care can also be used for nurse
practitioners to connect older adults in rural communities to specialists in larger centres, which
allows older adults to stay in their home community and avoid traveling for healthcare related
appointments (Clare, 2019; Ross et al., 2016). If there were an option for older adults to choose

37
virtual appointments via telemedicine and telehealth, nurse practitioners could promote improved
access to this population. Therefore, if nurse practitioners offered a service to older adults in a
rural community that provided virtual appointments via phone calls or video conferencing, this
could help decrease these environmental barriers apparent in the literature. This is essential when
looking at how nurse practitioners can help reduce barriers to access for older adults and how the
implementation of virtual care by nurse practitioners could reduce some of these environmental
barriers, thereby improving access to PHC services.
Another strategy discussed in the literature was home visits from nurse practitioners or
interdisciplinary team members (Clare, 2019). Home visits by PHC providers may not always
fall under coverage through Canada’s publicly funded healthcare system (ref). Private healthcare
organizations may continue to offer these services, and if nurse practitioners are working under a
private organization this could be something they could try to advocate for in practice or
advocate for an expansion of services in the public health model of care (Clare, 2019; Hunter et
al., 2016). Publicly funded healthcare systems improve population health while balancing the
need to provide high-quality healthcare with cost-containment and maximum efficiency (Clare,
2019). In Canada, public healthcare services typically target the largest users of expensive
resources: the aged and marginalized population (Clare, 2019). Clients may be willing to pay for
healthcare services like home visits, but there may not be much advantage to targeting this
demographic if the aim is reducing illnesses that result in hospital admission or emergency room
care. However, the not-for-profit public sector may find better value in offering house calls to
specific populations like the housebound frail or elderly (Clare, 2019). Therefore, if nurse
practitioners had the option to provide this service in the rural communities it could help reduce
barriers for older adults accessing PHC.

38
Interdisciplinary teamwork also plays a role for nurse practitioners in rural communities
to improve access and reduce barriers to PHC services for older adults. Weil et al. (2018)
suggested that interdisciplinary partnerships can improve rural care by addressing issues in a
team-based environment that may be too complex for one discipline or multiple disciplines to
solve. Therefore, this effective teamwork allows members to have an overall goal for patients,
establish shared and explicit goals, and work collaboratively to treat patient problems (Weil et
al., 2018). Thus, to improve older adults’ access to PHC services, nurse practitioners could
engage with interdisciplinary team members to reduce some of the barriers of access for older
adults, which are apparent in the literature.
With the current lack of geriatric specialists and services in rural communities to increase
access to PHC for older adults, Prasad et al. (2014) have suggested that a nurse practitioner-led
transitional care model which supports older adults’ transition between health sectors, manages
chronic diseases, and educates on health prevention can improve access to PHC. The
collaboration between the nurse practitioner, geriatrician, and family physicians highlights the
need to provide enhanced care for older adults within the PHC setting (Prasad et al., 2014). If
nurse practitioners could implement a model of care for older adults in rural communities, it
would be important to incorporate telemedicine components based on the community size.
Furthermore, if the model were to be a nurse practitioner-led model of care that implements
nurse practitioners into a family health team to aid in the management and support of frail, older
adults, this has also been shown to be successful to improve access (Prasad et al., 2014).
Important features of the nurse practitioner-led model of care for older adults are
highlighted below and can guide nurse practitioners in practice:
•

Nurse practitioners can play a central role in care of older adults.

39
•

Nurse practitioners and PHC providers form the core team in consultation with a
geriatrician and collaboration with community partners, as needed, including
families.

•

Nurse practitioners can provide early identification and intervention in health
promotion.

•

Nurse practitioners can provide access to Comprehensive Geriatric Assessment to
identify systemic, medical, and psychosocial concerns that place older adults at
risk.

•

Nurse practitioners (and other PHC providers) can arrange provision of care in the
least disruptive environment, most commonly in the individual’s home (Prasad et
al., 2014).

In addition to nurse practitioner-led models with the involvement of a geriatrician, or
geriatric specialized nurse practitioner, other models are available if these resources are not
offered. Although there was no clear model or approach that nurse practitioners could implement
into rural communities, the literature did provide models of care that may be better suited for
certain community sizes, such as rural and remote communities. Wakerman et al. (2008) suggest
that for a model of care to be successfully implemented in a community supportive policy,
community readiness, workforce organization and supply, funding, linkages, and government
management and leadership are necessary. Essential elements of sustainable PHC services for
small rural and remote communities include environmental enablers which help prepare an
environment for change to improve access to PHC services (Wakerman et al., 2008). These
enablers include: a supportive policy which ensures sustained service funding; co-ordination of
policy and funding across national and provincial governments; and an appropriate level of

40
community readiness for involvement in planning, implementation and monitoring of health
service activity (Wakerman et al., 2008). Therefore, to implement these strategies, nurse
practitioners in rural communities could do a community assessment and identify specific needs
of the older adult population.
Older Adults’ Perspective
According to the Age-Friendly Rural and Remote Communities: A Guide, older adults
would prefer to remain independent, with the ability to live autonomously in their own homes
(Gallagher et al., 2007). In rural communities, there is a lack or shortage of long-term care
options for older adults, and therefore, can result in the older adult having to leave the
community to access long-term care facilities (Gallagher et al., 2007). One of the participant’s
suggestions was the provision of a continuum of care in the community, from home care to
assisted living, to well-coordinated facility care (Gallagher et al., 2007). Therefore, nurse
practitioners could play a role in the promotion of continuity of care for older adults through the
addition of home visits to their practice in rural communities or as a liaison between PHC and
community-based care (Prasad et al., 2014).
Older adults also discuss the importance of contributing and benefiting from community
life through involvement in senior activities that promote physical activity and social or group
interactions (British Columbia [BC] Ministry of Health, 2014; Gallagher et al., 2007). Some
suggestions include the incorporation by healthcare providers and community members of
programs to improve access and reduce barriers to PHC services for older adults (Gallagher et
al., 2007).
For example, programs and interventions that other communities have implemented in
BC include:

41
•

East Kootenay Senior Caregivers’ Network: Rural provides information and
support for caregivers through local group meetings, buddy system, newsletter
and tollfree phone line (Gallagher et al., 2007).

•

Village of Lumby used funds from the Age-friendly Rural and Remote
Communities Initiative identified transportation as priority and provide low-cost
door-to-door transportation to area activities, events, and services (Gallagher et
al., 2007).

These programs are two examples of how nurse practitioners could collaborate with
community members and policymakers to reduce environmental barriers such as lack of
transportation, or support for spouses caring for their partners or family members in caregiver
roles for older adults.
Limitations
One of the main limitations of this integrative review is the lack of literature that is
specific to answering how nurse practitioners can reduce barriers for older adults accessing PHC
services. For instance, as previously discussed, multiple themes were revealed from the
literature, yet the literature does not give one straightforward approach that answers the how part
of the research question. The research discussed multiple barriers that older adults face with
accessing PHC services; however, there was a lack of a clear approach on how these barriers
could be addressed in practice. Therefore, the literature suggested ways that nurse practitioners
can collaborate with interdisciplinary team members and certain models of care that could
improve barriers such as geographic location, although a more specific approach needs
exploration in future research.

42
The types of evidence retrieved in the literature consisted of mainly qualitative and
quantitative studies. Most primary studies used convenience sampling or hand-selection of
participants, highlighting a risk for researcher bias. However, the qualitative research design
provided rich and valuable subjective experiences of older adults’ access to PHC services in rural
communities that collectively contributed towards informing the research question.
Implications for Practice
In practice, many nurse practitioners will be working with older adult patients in some
capacity. Thus, older adults need to receive access to PHC services to reduce the chronicity of
diseases and promote health prevention and longevity. If nurse practitioners are unaware of the
strategies available to implement into their practice, then older adults may not receive the
adequate care that they need. Nurse practitioners should be aware of how the lack of access to
PHC services can negatively affect older adults’ overall health.
Nurse practitioners improve the health of hard-to-reach populations challenged with
access and acceptability of traditional healthcare services (Grant et al., 2017). They bridge the
gap between older adults' hospital discharge and their next appointment with their PHC provider,
“advocate for clients and help them navigate complex services, and advocate to ensure timely
information sharing and implementation of a consistent treatment plan” (Grant et al., 2017, p.
54). They also provide a service that individuals may otherwise have difficulty accessing for
reasons including affordability, geographical isolation or extended waiting times (Grant et al.,
2017). Nurse practitioners working in rural areas also spend more time with their older adult
patients and therefore had a better understanding of how chronic conditions impact older adults’
daily lives (Falkenstern et al., 2005). Therefore, nurse practitioners and the inclusion of an

43
interdisciplinary team, are in position to reduce barriers to accessing PHC services for older
adults and enhance their general healthcare experiences.
Further, if nurse practitioners were to implement virtual care into practice for older adults
who may not have access to transportation, include home visits, and collaboration with
interdisciplinary teams, they can reduce barriers to older adults accessing PHC services. By
identifying barriers in rural communities where nurse practitioners work, a targeted approach to
improving access to vulnerable older adults can be achieved (Ford et al., 2018). With the support
of individual communities, there is an opportunity for close collaboration between health
authorities and healthcare professionals to improve access to PHC services. This improvement
can occur through more home visits, telephone or videoconferencing consultations,
multidisciplinary team partnerships, and role clarification (Dolovich et al., 2019; Weil et al.,
2018).
Nurse practitioners who demonstrate a connection to the rural community are more likely
to become trusted healthcare professionals (Hunter et al., 2016). This connection to the
community shows through interacting with patients, and mentorship from local physicians in the
context of connecting to the community, facilitating positive working relationships and a sense
of shared responsibility within the PHC team (Hunter et al., 2016). Interdisciplinary partnerships
can improve rural-care transitions by blending the skills of disciplines to increase the provision
of all-inclusive care (Weil et al., 2018). Healthcare professionals must support a targeted
approach to improving access when vulnerable older people use PHC services. Closer
collaboration between health authorities and providers to improve targeted services for the aging
population can lead to the improvement of access for older adults to PHC services (Ford et al.,
2018).

44
Future Research
Future research is needed to explore how nurse practitioners working in rural
communities can reduce barriers to older adults accessing PHC services. As indicated in the
literature, there are multiple barriers that older adults face when trying to access PHC services on
environmental, systemic, and individual levels. However, there is a gap in the research that
addresses how nurse practitioners working in rural communities can reduce these barriers.
Therefore, it would be pertinent for future research to focus on how nurse practitioners, as PHC
providers, can specifically address these barriers by using programs or tools and implementing
this into practice.
In Canada, there are also gaps in the extent to which each province has adopted, funded
and implemented the strategic components of improving access to PHC services for older adults.
For example, more federal leadership could facilitate collaboration and support healthy aging
initiatives across Canada, which can reduce the resources required for provincial and territorial
governments to develop stronger responses in rural areas still under development (SPHERU,
2018). Therefore, a review of implemented programs and policies to assess these principles and
strategies would be an area for future research (SPHERU, 2018). In the case of provinces and
territories still working to develop a strategy, review of existing strategies and interventions
offers the opportunity to identify and adopt best practices into their plans of action (SPHERU,
2018).
Conclusion
Reducing barriers for older adults in rural communities to improve access to PHC
services is a complex topic. The consequences of lack of access to PHC services for older adults
increases the necessity of PHC providers to incorporate strategies into their practice to prevent

45
poor outcomes. This integrative review examined strategies for nurse practitioners to reduce
barriers to access for older adults while working in rural communities. Through a comprehensive
literature search, relevant articles were reviewed, with eighteen articles selected. The analyzed
findings of these articles provided insight into how the reducing of barriers for older adults to
accessing PHC services by nurse practitioners working in rural communities can be applied to
the PHC context.
A synthesis of the findings highlighted the importance of incorporating virtual care
through telehealth and telemedicine modalities, implementing nurse practitioner-led models into
practice, and collaborating with interdisciplinary teams. Home visits by nurse practitioners and
role clarification were also two areas that could improve access to PHC for older adults.
However, the literature did not provide a straightforward approach that nurse practitioners could
implement to reduce barriers to access to PHC services for older adults. There are many
opportunities for future research from this integrative review. Additional research should address
strategies to promote programs or tools that nurse practitioners can implement into practice.
Strategies on federal and provincial levels in Canada must also be considered for future research
to promote healthy aging initiatives for older adults.

46
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nid=BD4D6FA870F048DE3982DFBDF8EA8FF6?sequence=1

health care access OR health
services accessibility OR
delivery of health care

primary health care OR
primary care
aged OR senior(s) OR elderly
OR older adult(s) OR older
person(s) OR geriatric(s)

Access

Primary Health Care

Older Adult

rural OR rural community(ies)
OR rural population(s) OR
rural area(s)

Rural Community

"Aged"[Mesh]

"Primary Health Care"[Mesh]

"Health Services
Accessibility"[Mesh] OR
"Delivery of Health
Care"[Mesh]

"Rural Population"[Mesh]

nurse practitioner(s) OR family "Nurse Practitioners"[Mesh]
nurse practitioner(s) OR
OR "Family Nurse
advanced practice nurse
Practitioners"[Mesh]

Nurse Practitioner

MeSH

Keyword

Concept

Concept Table for Search Strategy

Table 1

Aged

Primary Health Care

Health Services Accessibility
Health Care Delivery

Rural Population
Rural Area
Medically Underserved Area

Nurse Practitioners
Advanced Practice Nurses

CINAHL Heading

54

("Nurse Practitioners"[MeSH Terms] OR "Family Nurse Practitioners"[MeSH
Terms] OR "nurse practitioner*"[All Fields] OR "family nurse practitioner*"[All
Fields] OR "advanced practice nurse*"[All Fields]) AND ("Rural
Population"[MeSH Terms] OR "rural"[All Fields] OR "rural communit*"[All
Fields] OR "rural population*"[All Fields] OR "rural area*"[All Fields]) AND
("Primary Health Care"[MeSH Terms] OR "Primary Health Care"[All Fields] OR
"primary care"[All Fields]) AND ("Aged"[MeSH Terms] OR ("Aged"[MeSH
Terms] OR "Aged"[All Fields]) OR "senior*"[All Fields] OR "elder*"[All Fields]
OR "older adult*"[All Fields] OR "older person*"[All Fields] OR "geriatric*"[All
Fields]) AND ("Health Services Accessibility"[MeSH Terms] OR "health care
access"[All Fields] OR "Health Services Accessibility"[All Fields] OR "Delivery of
Health Care"[MeSH Terms] OR "Delivery of Health Care"[All Fields])
(("Advanced Practice Nurses") OR ("Nurse Practitioners")) AND (("Rural
Population") OR ("Medically Underserved Area") OR ("Rural Areas") OR ("Rural
Communities") OR ("Underserved Community") OR ("Underserved Population"))
AND (("Health Services Accessibility") OR ("Health Care Access") OR ("Health
Care Delivery")) AND (("Primary Health Care") OR ("Primary Care")) AND
(("Aged") OR ("Senior") OR ("Elderly") OR ("Older Adult") OR ("Older Person")
OR ("Geriatric"))
(nurse practitioner OR family nurse practitioner OR advanced practice nurse) AND
(rural population OR rural area OR rural community OR underserved community
OR underserved population) AND (primary health care or primary care) AND
(Health Care Access OR Treatment Barriers OR Health Care Delivery) AND (aged
OR senior OR elderly OR older adult OR older person OR geriatric)
(Nurse Practitioners OR nurse practitioner) AND (rural population OR rural area
OR rural community OR underserved community OR underserved population)
AND (Primary Health Care OR primary health care) AND (Health Services

Search Terms

Comprehensive Search Strategy (September 25, 2020)

Table 2

110

17

4

27

CINAHL

PsycINFO

Medline
(Ovid)

Total Number of Citations

PubMed

Database

55

Accessibility OR health care access OR Delivery of Health Care OR health care
delivery) AND (aged OR senior OR elderly OR older adult OR older person OR
geriatric)
TOTAL RETRIEVED
158

56

Concept

Rural Community
Rural population
Rural area
Underserved area

Nurse Practitioner
Family nurse
practitioner
Practitioner
Primary care
provider
Advanced practice
nurse

Brainstorming Concepts

Table 3

Accessibility
Services
Barrier
Delivery

Access

Primary Health
Care
Primary care

Aged
Elderly
Senior
Older person
Geriatric

Older Adult

57

"Aged"[Mesh] OR aged OR senior* OR elder* OR "older adult*" OR "older
person*" OR geriatric*
#1 AND #2 AND #3 AND #4 AND #5

#5

#6

#4

#3

#2

"Nurse Practitioners"[Mesh] OR "Family Nurse Practitioners"[Mesh] OR
"nurse practitioner*" OR "family nurse practitioner*" OR "advanced practice
nurse*"
"Rural Population"[Mesh] OR "rural" OR "rural communit*" OR "rural
population*" OR "rural area*" OR "Medically Underserved Area"[Mesh] OR
"medically underserved area*"
"Health Services Accessibility"[Mesh] OR "health care access" OR "health
services accessibility" OR "Delivery of Health Care"[Mesh] OR "delivery of
health care"
"Primary Health Care"[Mesh] OR "primary health care" OR "primary care"

#1

PubMed Search and Results

Table 4

TOTAL=110

5,592,486

288,782

1,093,042

200,051

26,656

58

Eligibility

Screening

Identification

59
Articles identified through database
searching
(n =158)

Article titles/abstracts
screened based on
inclusion/exclusion criteria
(n = 129)

Full text articles included
in the literature search

Included

(n= 31)

Final full text articles
included in the literature
search
(n= 18)

Articles excluded: titles
and abstracts irrelevant
(n = 98)

Articles excluded with full
text review: did not meet
inclusion criteria
(n = 21)

Additional records identified
through other sources
(n = 8)

Figure 1. Literature Search Flow Diagram for Search Conducted September, 2020

Study
Design

Systematic
review of
qualitative and
quantitative
research.

Author(s),
Date, &
Country

Batsis et al.
(2019),
United States

-Systematic
review,
according to
PRISMA
guidelines.
Search of
PubMed,
Cochrane
Library, Web
of Science,
CINAHL,
EMBASE and
PsycINFO.
N=17
-Participants
were an
average of
65.1 years to
86.45 years.

Sample

-To appraise the
evidence which
outlines
telemedicine
interventions
conducted in
older adults in
non-hospital
settings through
the evaluation of
both rural and
urban studies.

Purpose

Evidence Matrix of Literature Reviewed (N=18)

1)Remote and rural
locations.
2)Lack of resources:
limited specialists.
3)Transportation.
4)Socioeconomic
disparities.
5)Less experience
with emerging
technology.

Barriers to
Access

Appendix A

-Telemedicine
care delivered
either in home or
in an assisted
living/long-term
care setting
-Telemedicine
had to be live,
real-time,
synchronous, or
two-way video
conferencing on
both the
receiving and
delivery end.

-Telemedicine
interventions are
feasible among
older adults
regarding
acceptability,
adherence, and
self-reported
function.
-4 studies focused
on fall, exercise, or
strength-based
measures and
demonstrated
improvements in
all areas with the
use of
telemedicine.
-3 studies reported
that improved
cognitive function
was found by using
telemedicine.
-5 studies reported
no difference in the
improvement of
utilization
parameters.

Interventions Key Findings

-Eligibility criteria
for participants are
clearly
demonstrated.
-Study-level
outcomes were
evaluated based on
effectiveness and
acceptability of
outcomes.
-Authors focused
on peer-reviewed
publications and
omitted gray
literature.
-Cochrane
Collaboration’s
Risk-of-Bias Tool
used.
-Authors have not
formulated
focused research
question.
However,
objective of the
review is clear.
-One independent
assessor manually
reviewed included
articles for
additional studies.

Strengths &
Limitations

60

Bresick et al.
(2016), South
Africa

Quantitative
study. Crosssectional
design.

-13 primary
care facilities.
-Each
reflected user
and staff
diversity.
-User sample
size based on
PHC measures
from a
previous
PCAT study.
-1432 users
interviewed.
-87 full time
doctors and
nurses
working in
PHC.

-“To obtain a
baseline measure
of performance
and organisation
at comprehensive
PHC facilities by
determining
users’ experience
and mangers’ and
practitioners’
assessments of
PHC” (p. 2).
-“Determine gaps
between users’
experience of
PHC and desired
performance on
the universally
accepted essential
PHC domains
and to identify
those that need
strengthening,
and aligning with
evidence-based
care and with
provincial and
national health
plans” (p. 2).

1)Sociodemographic:
unemployment,
education level.
2)Lack of
relationship and trust
with PCP.

-Use of PCAT to
determine the
extent to which
PHC is “aligned
with the
evidence for
cost-effective
care based on
users’ access to,
and utilisation in
their care, of
first contact
access, ongoing
care,
comprehensive
care,
coordinated
care, family and
communityoriented care
and cultural
competence” (p.
2).

-Urban users
scored first contact
access and cultural
competence
significantly higher
than rural users,
whereas rural users
scored
coordination,
comprehensiveness
(services
available), services
provided and
family-centredness
higher.
-Users scored
39.9% vs. 62.4% of
practitioners and
managers on
comprehensive
care provided.
-Practitioner scores
are (77%) vs. users
and managers (52%
and 45%,
respectively) on
family-centered
care.

-Field work
management and
data quality
control done by
experienced
research assistant.
-3-day training
workshop to
administer the
PCAT.
-Use of EpiData
and exportation to
Stata version 12.0
for statistical
analysis.
-Multivariate
binomial
regression analysis
was used.
-90% acceptance
rate for
questionnaires of
users; 71% for
practitioners and
74% of managers.
-Assured
anonymity to
respondents;
identifiable and
personal info not
required.
-Sampled each
PCF over 5 days
“may not represent
the user
experience other
weeks of the year

61

Clare (2019),
Canada

Quantitative
study. Pilot
project design.

-3 types of
participants
invited:
current clients,
clients
identified by
company
physicians
who might
benefit or
want house
calls (chronic
disease or
mobility
issues); and
persons in
community
who might be
interested in
service.
-Sampled via
snowball
sampling.

-To evaluate the
feasibility of
providing house
calls and
telehealth
services using
NPs.

1)Lack of homebased services.
2)Decreasing PCP in
rural communities.
3)No telehealth or
telemedicine options
for patients.

-Services
offered:
comprehensive
physicals and
screening for
disease,
treatment of
acute and
chronic
conditions,
phlebotomy and
specimen
collection,
prescribing,
referrals to
specialist, health
promotion
counseling,
integration of
illness
prevention
strategies, and
selfcare
education.
-Telehealth
services (video,
email, or phone).
-“NPs were
available for
house calls on
weekdays from
10 am to 7 pm
and rotated on-

-NPs, initially, felt
overwhelmed
managing large
workload.
-Obligations to
provide efficient,
timely care was
difficult to achieve.
-Home visits
provided an
opportunity for
history-taking and
patient assessment
that increased NPs
comfort with
virtual calls.

-Misener Nurse
Practitioner Job
Satisfaction Scale
used.
-No formal ethics
application done
due to time
constraints.
-Business goals
may have
conflicted with
conventional
research process.
-Convenience
sampling relying
on current clients
limits
generalizability.
-Equal
representation of
each cohort not
obtained.

given the changing
operational and
seasonal effects”
(p. 10).

62

Quantitative
study.
Randomized
controlled trial
design.

Quantitative
study with
survey design.

Dolovich, et
al. (2019),
Canada

Falkenstern
et al. (2005),
United States

-122
communitydwelling
adults aged 55
years and
older who

-158
intervention
and 154
control
participants.
-Participants
>70 years old
rostered with
the McMaster
Family Health
Team, living
in Hamilton
Ontario.

-"To compare
elders' selfratings of the
impact of their
chronic
conditions with

-To evaluate the
Health Teams
Advancing
Patient
Experience:
Strengthening
Quality program
and determine if
implementation
of the program
allows older
adults to obtain
their health goals
more effectively.

-N/A

1)Lack of
interdisciplinary
teams.

-Elderly
participants were
instructed to rate
the impact of
each of their
chronic

call duty on the
off hours so that
access was 24/7”
(p. 21).
-Designed a
multicomponent
and multistage
intervention with
the participation
of patients,
volunteers,
health care
providers and
community
representatives.

-Older adults
assigned a
significantly lower
mean impact rating
than healthcare
providers to 8 of

-No statistically
significant
differences
between groups
with outcomes
reported by patients
at 6 months.
-Lower rate of
hospital admission
in intervention
group vs. control
group (6.96% vs.
14.94%).
-Fewer medications
used in intervention
group vs. control.
-Increase in PHC
engagement.

-Participants were
informed in
writing that no
identifying
information
included.

-Applicable to
real-world
practice.
-High response
rate from
participants.
-In-depth data
analysis.
-Large sample size
of participants;
10% loss to
follow-up
accounted for.
-Trial masked, not
blind.
-Researchers had
access to files
identifying patient
randomization
status.
-6-month trial may
have been too
short, preventing
researchers from
fully examining
goal-directed care
of older adults.

63

Ford et al.
(2019),
United
Kingdom

Quantitative
study.
Randomised
controlled trial
design.

-34 patients
recruited (26
female, 8
male)
-Participants
were patients
aged 64 years
or older. Mean
age of 81.6
years.
-Four general
practices were
recruited

attended a
health
education or
exercise
program.
-25 men and
97 women
with an age
range of 55-88
years; mean
age of 70
years.

-To assess the
feasibility of a
trial design and
context-sensitive
intervention.
-To assess the
ability of
practices to
develop and
implement their
own service
changes and
acceptability of
the processes.

healthcare
providers'
estimates of the
impact of the
same conditions
on older adults"
(p. 195).
-How healthcare
providers' impact
ratings for
chronic
conditions are
affected by length
of time in clinical
practice and
having rural or
urban older adults
as patients.

1)Age.
2)Chronic
conditions.
3)Transportation.
4)Rural areas.
5)Lack of available
appointments.
6)Interactions with
receptionists.

conditions. All
affirmative
responses were
scored on a scale
from 1 to 4, with
higher scores
reflecting greater
impact.
-Means for the
older adults’
ratings of impact
were then
calculated for
each of the 11
conditions by
averaging the
affirmative
responses.
-Healthcare
providers’
impact ratings
were calculated
by averaging
estimates of
impact for each
health condition.
-Practices
allocated to the
intervention arm
were asked to
improve the ease
of the booking
system and
transport options
for socioeconomically
disadvantaged
older people
without access
to a car.
-Impact of
interventions:
fewer complaints,
call stacking
system well
received, more
receptionists
needed.
-Practices
successfully
designed and
implemented their
own contextsensitive service

the 11 chronic
conditions.
-Physicians with a
mostly rural
clientele were
significantly closer
to the older adults’
self-ratings of
cancer impact.

-Ethical approval
from NHS North
East National
Research Ethics
Committee.
-Freedom for PHC
practices to
develop their own
service change.
-Sample size
adequate for what
researchers were
looking for

-Informed consent
given.
-Human Subjects
Committee's
approval was
obtained.
-A panel of 8
physicians
reviewed content
for validity and 7
APNs.
-Under
representation of
men in the study.

64

Ford et al.
(2018),
United
Kingdom

Qualitative
study.

-Total of 15
participants.
-Interviews
with adults
over 65 years
of age and
focus groups
with
healthcare
professionals.
-Participant
age ranges
from 67 to 87
years old with
average age of
78.

-To explore
barriers to PHC
for socioeconomically
disadvantaged
older people in
rural areas by
identifying
barriers and
understanding
how these
barriers affect
access.

1)Breach of social
contract.
2)Difficulties with
engaged telephone
lines.
3)Lack of
appointment times.
4)No home visits.
5)Receptionists were
negative toward
patients.
6)Inability to receive
telephone
consultation vs. inperson visit.
7)Lack of
transportation.
8)Marginalization
due to age.

-N/A

-Practices were
given a support
manual,
containing an
evidence
summary and
trial
requirements,
four
development
meetings with
the lead
researcher over a
4-week period
and a grant of
£1500.

Themes: social
contract, impact of
physical resources
and skills, views on
expectations of
health services and
aging, service
constraints, and
need for targeted
services for this
age group.

changes based on
development
meetings.

-3% response rate
initially due to the
inclusion criteria
that participants
must not have
access to vehicles.
-Low response
rate of 37.3% for
post
questionnaires
may lead to
inadequate
validity of data
results.
-Unclear how
participants were
recruited prior to
randomisation of
practices.
-Researcher roles
were thoroughly
explained in data
collection.
-Rigour and
trustworthiness
ensured through
coding, generation
of themes,
accuracy check of
transcriptions, and
review of themes
by team and
representatives.
-Comparison
approach used to
avoid
confirmation bias.
-May not have
reached full
saturation with

65

Grant et al.
(2017),
International

Scoping
review design
of qualitative
and
quantitative
studies.

-74 articles
included in the
review from
developed
countries
(Canada,
Netherlands,
US, UK,
Slovenia,
Guam, &
Australia).

-To explore how
the NP role has
been taken up to
primary health
care settings in
developed
countries.
-To summarize
evidence of
efficacy of these
roles.

9)Feeling like
concerns were not
heard.
10)Services that are
not user-friendly for
older adults.
11)Restricted
resources (time spent
with patients), home
visit options.
12)Rural areas.
-N/A
-N/A

- “NPs work with
vulnerable
populations in rural
areas such as the
frail or elderly” (p.
54).
-NP interventions
resulted in positive
outcomes for
individuals and
groups.
-Outcomes varied
from physiological
data, hospital
admissions, use of
health services,
self-reported
health, cost
savings, and
morality/morbidity.

-Search strategy
explained well
using key nursing
electronic
databases.
-Dates clearly
identified.
-Exclusion and
inclusion criteria
clear.
-Studies were
evaluated using
the CASP tool.
-Quality of articles
was rated
moderate to high
(n=66 out of 74).
-Results consistent
with those of past
research regarding
NPs having the
capacity to work
with
socioeconomically
disadvantaged
populations.

third and fourth
focus groups.
-Member checking
not done

66

Qualitative
study.

Mixed
methods study.

Heale et al.
(2018),
Canada

Hewitt et al.
(2019),
United States

-2 focus group
sessions were
conducted
with a sample
of 8 rural
community
members each.
-5 males and 3
females in
each focus
group.

-8 NPs
included in
sample.
-Interviews
conducted
from Dec
2015-2016.
-NPs were
recruited to
participate in a
telephone
interview from
4 NPLCs
located in
Ontario
-Communities
were
traditionally
underserved
with high
numbers of
patients who
had no access
to primary
health care
services.

-To examine
perceived access
to PHC through
data generated
from two focus
groups, and to
propose practical
solutions to
perceived
barriers.

-To identify
potential gaps, or
issues in
healthcare
delivery at
NPLCs.
-To determine
how NPs in
NPLCs evaluate
the impact of the
NPLC model on
the quality of
care they provide
to patients with
diabetes and
multimorbidity.

1)Needs unmet by
PCP (quick
appointment times).
2)Lack of available
appointment times.
3)No immediate care
services over the
weekends or
evenings.
4)Lack of speciality
services.

1)Patients not
accustomed to
working with
interdisciplinary
teams.
2)Mental health
issues.
3)Transportation.
4)Hidden costs of
community services.

-N/A

-N/A

Three relevant
concepts:
1)Patients chose to
visit immediate
care clinic when
unable to see their
own PCP.
2)Patients visit this
clinic whether they
are publicly,
privately insured,

Themes: 1)Limited
access to provider;
often did not have
primary health care
for many years,
undiagnosed
chronic conditions.
These patients
needed a higher
level of care.
2)Interprofessional
team functioning;
supportive
environment; less
community
referrals because
the team was
accessible.
3)Role
clarification.

-Consent given by
participants.
-Used review of
transcripts,
classified data into
themes for data
analysis.
-Small sample
size. May not be
generalizable.

-Ethics approval
received by
Laurentian
University
Research Ethics
Board.
- “Audit trail
established
through
compilation of
research protocol,
review of
documents, and
summaries of
interviews which
enhanced
trustworthiness of
data gathering” (p.
555).
-Credibility
through crosschecking and
verification of
themes with other
sources.
-No discussion if
data saturation
was reached.

67

Hungerford
et al. (2016),
Australia

Mixed
methods study.

-NPs,
managers,
medical
practitioners,
and allied
health
workers.
-Older adults
> 65 years of
age.

-1 participant
aged 30-44
and all others
were age 65 or
older.

-To discover how
patients saw their
ability to access
PHC, what they
perceived as
barriers, and what
they thought were
possible
solutions.
-To evaluate NP
models within
Australia and
provide a
comprehensive
description of
community-based
clinic-located NP
models.
1)Rural and remote
areas.
2)Lack of age
specific PHC models
for older adults.

5)Language.
6)Culture.
7)Lack of trust with
PCP.
8)Financial barriers.
9)Rural areas.

-N/A

-Implementation of
the communitybased, cliniclocated NP model
provided residents
with a more
comprehensive
approach to the
delivery of
healthcare,
reducing their
travel time to
consult a GP.
-Challenges to the
model included the
organisation’s
limited capacity to
back-fill the NP for
leave and
professional
development
entitlements.
-Need for the
organisation to
explain the NP role
more clearly to
patients.
-Inclusion of an
additional
component of the
nursing model:

or uninsured.
3)Patients visit
immediate care
clinic regardless of
if they have a PCP.

-Authors
mentioned reasons
why they used a
case study design,
and noted the
potential
weaknesses
involved.
-Case study design
may cause
findings to limit
generalisability;
however, findings
can still be
transferable to
similar context.
-Part of large-scale
Australian study
that incorporated
NP models of
care.
-Ethics approval
received.

68

A mixedmethods study
using semistructured
interviews and
questionnaires.

Quantitative
study.

Hunter et al.
(2016),
Canada

Prasad et al.
(2014),
Canada

-Older adults
aged 65 years
and older

-14 patients,
one HCP, two
LLs, and one
NP
-200 randomly
selected
patients under
NP panel were
mailed
surveys with
41 returned.

-To develop a
model of care for
older adults to

-To study a
communityinitiated rural NP
practice and
formulate
recommendations
for other rural
communities.
Aim to determine
benefits and
challenges of a
rural PHC NP
role.

1)Chronic conditions
and comorbidities.

1)Lack of role
clarification.
2)Funding for PHC
NP.
3)Lack of access for
NP’s ongoing
education and role
isolation.

-NP–Geri and
PCPs form the
core team in

-N/A

influence of
context.
-Positive trends in
diabetes and
dyslipidemia
management.
-Slightly negative
trend in
hypertension
outcomes.
-Increase in access
to PHC services,
addressing mental
health and chronic
disease
management
service gaps.
-NP services
average
$903.44/day using
base FFS schedule,
not including
chronic disease and
rural service fees.
-Interdisciplinary
collaboration
between physician
and NP.
-90% of
respondents agreed
that NPs
explanation of
illness and injury
were strong.
-92% of patients
would return to NP
or refer a friend.
-Collaboration
between nurse
practitioners,
-Unique
ecosystem
approach which

-Use of multiple
data sources and
methods.
-Transferability of
findings is limited
by small sample
size and single-site
study approach.
-Risk for bias
from sampling a
limited number of
records to describe
NP practice, and
from those who
participated in
surveys and
interviews.
-Limited response
from rural HCPs
did not allow
study to
effectively capture
their insights.
-Low response
rate of surveys
(21%).

69

Retrospective
design.

living in rural
North Perth,
Ontario

increase access to
PHC and to
improve the
quality of care
they receive
through
collaboration
with other
healthcare
professionals.

2)Transition between
health sectors for
older adults.
3)Lack of follow up
care.
4)Lack of education,
management, and
support.

consultation
with a
geriatrician and
collaboration
with community
partners.
-NP-Geri
assesses
individual needs
and health
service delivery,
working across
sectors.
-Twice-monthly
visits to
retirement
homes.
-Case-finding in
collaboration
with PCPs,
community, and
acute care
partners.
-Early
identification
and intervention
and health
promotion.
-Access to
Comprehensive
Geriatric
Assessment to
identify at risk
elders.
-Transition from
sector to sector
in person when
possible and
with written,
verbal, and

geriatricians, and
PHC providers can
have a positive
effect on the
functional status of
older adults in
hospital, improve
their overall wellbeing, and reduce
hospital admissions
and
institutionalization.

include multiple
collaborative parts
to provide
improving quality
of life for older
adults and
improving access
to care.
-Relatability to
real-world
problems; this
program could be
taken and
implemented in
other areas with
NP.
-Unclear how an
NP who is not
specialized in
geriatrics would
be affected.
-The retrospective
design of the study
is a potential
weakness as the
initial data used
for comparison
may be of poor
quality.

70

Ross et al.
(2016),
Canada

Quantitative
study.

-60 patients,
all members of
the First
Nations band
-Most
common age
group 19-35;
variety of ages
were seen
from less than
1 year to over
90 years of
age.
-25% were 55
years and
older.

-To determine if
the use of
telehealth can
improve access
and continuity of
care in PHC.
-To bridge the
gaps in provision
of specialty care
in Alberta by
implementing
video telehealth
technology to
connect rural
residents with
PCPs or
specialists.

1)Geography.
2)Availability of
PHC services.
3)Language.

electronic
communication.
-Discharge
planning and
follow-up.
-System
navigation
support to
ensure access to
available
community
supports and
resources.
-Ability to drive
for distant home
visits.
-Telehealth
technology such
as digital
stethoscope, or
other assessment
tools, video call
for provider to
control camera
settings for
patient to have
telehealth
appointment.
-34% of patients
were seen for
rashes, followed
closely by
prescription refills
(24%), pain (14%),
URTI/flu (10%),
other (16%).
-All felt the wait
time was
acceptable and
most were able to
get same-day or
next-day
appointments, very
east to book
appointments.
-All indicated they
would use the
service again.

-Stakeholders
included were
physicians, NPs,
RNs, community
health members,
receptionists, and
LPNs.
-Wide range of
ages of
participants
indicates
generalisability.
-Feasibility and
sustainability of
project were
thoroughly
assessed by
authors.
-May not be
generalizable to
non-First Nations'
communities.
-12-week program
was not long

71

Shah et al.
(2017),
Canada

Qualitative
study.

-5025 GPs and
423 NPs
included.
-Data for
physicians and
NPs used from
2014 CIHI
database.
-Used
communitybased GP and
NP who
provided
direct care
services
outside acute
care settings.

-To examine and
compare the
geographic
accessibility to
two front line
PHC services in
the two Canadian
provinces of
Saskatchewan
and Alberta
focusing on how
NPs are
distributed in
comparison with
GPs at the
municipal level.

1)Shortage of
healthcare providers.
2)Age.
3)Chronic
conditions.
4)Rural areas.

-N/A

-Inequities found in
the distribution of
PHC services
across Alberta and
Saskatchewan
within more rural
and remote
municipalities.
-10.80 vs 9.29
access score for
GPs in Alberta vs
Saskatchewan.
-NP access score
.70 vs 1.42 in
Alberta vs
Saskatchewan.
-No significant
correlation between
GP and NP access
scores in both
provinces.
- “Results
demonstrate NP
services may be
addressing gaps in
family physician
access in poorlyserved categories”
(p. 100).

enough according
to some
stakeholders and
participants.
-3SFCA method
was applied to
estimate access
score or
geographic
accessibility; used
previously many
times for health
care services.
-Very thorough
and well-described
method section.
-Multiple figures
included in paper
which were easy
for reader to
follow.
-Pearson
correlation test
used with
statistical software
to analyse how
NPs are
distributed vs GPs.
-Distance
parameter
included to
increase validity.

72

Quantitative
study.

Systematic
review.

Shah et al.
(2019),
Canada

Wakerman et
al. (2008),
Australia

-Databases
searched:
Medline,
CINAHL,
EBM
Reviews,
AMED,
OVID,
APAISHealth,

-Data acquired
from Health
Force Ontario
and Marketing
Recruitment
Agency, and
2016 Census
Canada.
-GP and NP
data for
Ontario was
included

-To review the
available
published
literature on
innovative
models of
comprehensive
primary health
care in rural and

-To present a
conceptual
partnership
model that
integrates
nursing,
gerontology, and
public health
disciplines for
support of ruralresiding older
adults.

1)Rural and remote
locations.
2)Reduced access to
PCPs and health
services.
3)PHC models that
are not specific to
community size and
population.

1)Rural areas.
2)Transportation.
3)Sociodemographic
characteristics of
individuals.
4)Inability to retain
PCPs to rural areas.

-N/A

-N/A

-7.1% of
province’s FPs
practised within the
area of SWO.
-68.3% of FPs
provided PHC, and
31.7% worked
alternative practice
models.
-FPs in rural
communities often
worked in the ER
department as well
or did other
specialties.
-Accessibility score
in SWO 6.59 PCPs
per 10,000; higher
than provincial
average of 6.03.
-Geographic
accessibility for
rural areas and
medium population
centres were lower.
-Most areas with
low accessibility
and higher % of
seniors were
located near
London.
-Discrete PHC
services to sustain
general practitioner
service in rural
areas experiencing
difficulty with
retention (e.g.,
incentives).

-Analyzed data
through a
geospatial
approached called
E2SFCA.
-Used Network
Analyst to
implement data.
-Used choropleth
mapping approach
with standard
deviation
classification
scheme.
-May not be
generalizable to
more remote
communities
throughout
Canada.
-The interpretation
of full-time
equivalent PCP
hours may not
have reflected the
times rural
practitioners spent
doing other
specialities within
community due to
lack of providers.
-Central concepts
clearly defined
according to
inclusion and
exclusion criteria.
-Comprehensive
search; included
peer-reviewed
articles, grey

73

Weil et al.
(2018),
United States

Quantitative
study.

-Program
developed by
Nursing and
Public Health
faculty.
-Led by
ACNP who
previously
directed an
adultgerontology
NP program.
-Nurses were
trained to be
APNs in rural

ATShealth,
EMBASE,
H&S,
INFORMIT,
Meditext, and
RURAL.
-Dates: 19932005.

-To examine the
historical and
conceptual basis
of public health,
with a specific
focus on health
disparities in
elderly and rural
populations on
both an
individual and
population levels.

remote Australia
to identify what
models work
well, where, and
why.

1)Rural areas.
2)Age.
3)Lack of specialized
care.
4)Lack of effective
interdisciplinary
approach.

-Communitybased course led
by ACNP to
bring together
the best
practices in
community
health, nursing,
and gerontology.

-Preceptor
development and
recruitment in the
rural and frontier
areas.
-Development of
relationships and
work with new
preceptors as
partners is
important for
improving
interdisciplinary
partnerships.
-Limited number of
AGACNPs exist to

-Integrated
services, ‘shared
care’ model.
-Comprehensive
primary health care
services addressing
Aboriginal
community
members.
-Outreach models,
‘fly-in-fly-out’
method.
-Telehealth and
telemedicine.

literature, and web
searches of
government
departments,
workforce
agencies, etc.
-Results
interpreted
through clear
tables: rural and
remote PHC
models, and
environmental
factors/essential
service
requirements.
-Does not discuss
specialized PHC
models for older
adults; may have
different outcomes
if a model were
implemented with
this population.
-AGACNP was
first of its kind in
the region.
-Timelines were
restricted so the
team had to
rapidly plan and
carry out tasks.
-More time might
be needed in
future programs to
develop
relationships.
-Generalizability
is noted, as this
program could be

74

and frontier
areas.

serve as preceptors,
and those in rural
and frontier areas
have fewer
technology
resources available
to them for online
preceptor training.

implemented in
other areas to
include rural
nurses.

75